Restrictive regulation constrains delivery of an integrated, collaborative and responsive health sector.

Abstract

Regulation of health practitioner practice is common in most jurisdictions. Consumers of healthcare services expect regulation to ensure public accountability and transparency of decision-making relating to practitioners' practice; employers look to regulators to influence positively the quality of service delivery, and governments support regulation as a means of providing them with confidence in health sector investment. Those practitioners who are not regulated either seek to be so or are self-regulating, either to preserve practice standards and/or to increase status and income. But the principal reason why health sector regulatory systems exist is to achieve the wider social goal of assuring public health and safety, and to hold health practitioners to account. Few health practitioners would see these objectives as problematic. But to what extent does regulation constrain moves to increase public access to healthcare and improve health service delivery? Health sector regulation governed by legislation usually involves establishment of a third-party public agency that has overall responsibility for the performance of a profession or group of professions.1 The regulatory agency administers an accountability framework for those health practitioners for whom it has responsibility, determines scopes of practice within which practitioners are competent to practise, and implements systems to ensure that health practitioners do not practise outside their respective scopes of practice. Regulatory agencies have a role in determining the education and training required to practise in any vocational scope and also in the professional development requirements for ongoing practice. In the case of self-regulating professions, health practitioners establish a similar separate regulatory regimen for their respective professions, although they do not operate with a statutory mandate. Commonly, regulatory agencies adopt an approach focussed on compliance, rather than deterrence.1 Health practitioners are assumed to have a commitment to good practice and therefore to be responsive to advice and support. In principle, implementation of this paradigm for the purpose of regulation in the health sector assures public health and safety. However, regulatory agencies have a responsibility to consider the wider, sometimes negative, impacts of regulation, including whether restrictive regulation may negatively impact public safety or access to healthcare services. The focus of regulatory agencies on the practice of specific professional groups, including determination of vocational scopes and associated education and training requirements, supports specialisation – itself, usually associated with quality expectations. But specialisation, and what some may describe as overspecialisation in the heath sector, is contributing to workforce shortages and exacerbating the current maldistribution of health practitioners through a contribution to workforce inflexibility.2 Where there are shortages in specialist groups, or changing patient needs, employers often have limited options to respond. Unless regulatory agencies have established appropriate delegation guidelines (e.g. where nurses may delegate tasks to healthcare assistants) or there are expanded scopes of practice that enable role substitution, employers cannot ask health practitioners to take on tasks that fall outside the constraints of an approved vocational scope. In some instances, there may be insufficient work for more than a certain number of health practitioners. But the limitation in practitioners' scopes of practice can mean that more staff than necessary must be employed to obtain the diversity of vocational scopes necessary to meet patients' needs. This increases the burden of cost on the health sector. Where there are national shortages in a particular type of health practitioner, as can be the case for medical specialties, employers may try to fill vacancies by employing overseas-trained practitioners. But regulatory authorities can restrict registration of overseas-trained professionals on the basis that their qualifications and/or experience are insufficiently similar to those of locally trained practitioners. In so doing, regulatory authorities are performing their regulatory role, but there is seldom room for flexibility to address areas of critical national shortage. In the case of some health professions (e.g. in some allied health professions), restrictive regulation can be reflected in narrow scopes of practice and tight education and training requirements overseen by regulatory authorities. Consequentially, as technology changes or workforce demands fluctuate, there are limited opportunities for practitioners to enter related specialities without having to undertake significant retraining. This limits career options and has a negative impact on staff recruitment and retention. But not all regulation is overly restrictive. It is important to note too that regulation can be the stated reason for retention of the status quo, when in fact the disincentive to change is either practitioners' perceived loss of autonomy, possible competition or threat of reduced income. Some regulatory agencies are particularly proactive in their response to healthcare trends and quick to consult on vocational scope changes that might support future practice. But the need for all those who have a leadership role in health regulation to take account of healthcare trends and for regulation to make a positive contribution to changes in service delivery is becoming critical. As government health budgets reduce in real terms, chronic long-term conditions become more prevalent, technology changes make new interventions possible and others redundant, and the population ages, new models of care must be developed. These need to provide improved access to early and preventive healthcare, a better continuum of care and improved patient experience. Workforce flexibility, innovation, integrated teamwork and client-centred approaches are central to such outcomes being achieved. Restrictive regulation has no place here. Opportunities for practitioners to take on expanded roles, to undertake, or be specifically trained to undertake tasks more usually performed by other health professionals must be fully supported by regulation. Regulation must be proactive and responsive.3 But how is such regulation best achieved? Responsive regulation requires what Walshe (2002) describes as ‘tripartism’, that is the co-design of regulatory mechanisms by working with and through consumers, practitioners, employers and other key stakeholders. In this model, all parties become ‘agents for change’.1 The specific engagement of consumers, including on governance boards of regulatory agencies, ensures that there is a focus on consumer experience, not simply the achievement of health outcomes. A more radical approach to advancing service improvement and implementing new models of care could be for regulatory agencies to cease to regulate specific health practitioner types (e.g. medical specialists or nurse practitioners) as competent to practise within particular scopes of practice. Instead, they might regulate the services and practices that have potential for harm.4 This would mean regulating practices undertaken by more than one type of health practitioner (doctor, nurse, allied health professional), with an emphasis on the competencies necessary to deliver services. For example, instead of an anaesthetic technician and a perioperative nurse being separately regulated by different regulatory agencies to provide anaesthesia support, the same practices undertaken by each of the health professionals might be regulated by the same regulatory agency. Such an approach would ensure equivalent competencies across professions where similar tasks are being performed and strengthen assurance of public health and safety. Importantly too, this approach would enable better use of the existing health workforce where workforce capacity is otherwise limited and would also support implementation of new approaches to service delivery. Integrated teamwork is also essential for implementation of new models of care. For patients to experience a continuum of healthcare, health practitioner practice should be characterised by seamless handover, timely and appropriate decision-making, and evidence-based intervention. Regulation can play an important part in promoting and supporting such practice. Regulatory agencies approve continuing professional development requirements and reaccreditation requirements for health practitioners. But how often do we hear practitioners bemoaning the length of time they spend on what are perceived to be merely exercises in compliance? Continuing professional development can be so much more. It can be the vehicle by which health practitioners learn to challenge the status quo through engagement in new ways of working, including collegial decision-making in the context of committed multidisciplinary teams. But to do so, regulatory authorities must see beyond professional boundaries and promote and support complementary ways of working, knowledge sharing and collaborative decision-making between different types of health practitioner. In so doing, regulation can become a significant contributor to service improvement, rather than an inhibitor of it. There is no doubt that regulation has a significant role to play in the modern health system. But regulation must play a more prominent role in the health sector of the future. As health funding becomes more constrained and new models of care are developed, regulatory authorities need also to consider how they might collaboratively work with patients, health professionals, education and training providers, and employers to increase patients' access to healthcare services, improve the quality of the services they receive and address workforce shortages that currently limit patient healthcare options.